The following has been reprinted with permission from Paul Terdal. Dr Thomas feels that this is a positive step, and wished to share this with you, his friends and followers. You may also click the included links to learn more!

Kaiser Permanente is now officially covering Applied Behavior Analysis
I am very pleased to report that Kaiser Permanente is now officially covering Applied Behavior Analysis (ABA) therapy as a treatment for autism and related neurodevelopmental disorders in Oregon and Washington.

Here is an excerpt from a letter that I received from Kaiser yesterday, describing its’ official coverage policy for treatment of “autism, pervasive developmental disorder, neurodevelopmental disorder or other diagnosis”:

“If a Permanente developmental specialist determines that a member with commercial coverage meets Kaiser Permanente medical necessity criteria for a service, including that the member is likely to exhibit significant, measurable and sustainable health improvement as a result of receiving the service, a treatment plan will be developed which may include one or more of the following: physical therapy, occupational therapy or speech therapy; sensory integration (SI) under the Occupational Therapy (OT) services benefit; or Applied Behavior Analysis (ABA) or other mental health services under the Mental Health benefit. Coverage is subject to benefit requirements, limitations, and exclusions, and may be different for members with Medicare and Medicaid coverage.” (underline original; boldface added)

It is important to note that Kaiser has defined ABA as a form of mental health service “under the Mental Health benefit.” This is legally and medically correct; under group plans, this generally means that there can’t be any contractual limits on age, number of visits, or monetary cost. Kaiser can legally limit care to services that are medically necessary, and would be within its’ rights to assert that a particular patient would not benefit from ABA therapy. Any such denial would be subject to the administrative appeals process including a binding External Review by an Independent Review Organization appointed by the Oregon Insurance Division. Many of Kaiser’s individual plans do legally impose limits on outpatient mental health care, and coverage of ABA would be subject to those same limits, since individual plans are exempt from both state and federal mental health parity laws.

This new ABA coverage does not apply to Medicaid (the Oregon Health Plan), which currently prohibits its’ contracted insurers from covering ABA (this OHP policy is probably a violation of Federal law, as per recent court orders and settlement agreements in Florida, Washington, and other states).

The details of Kaiser’s implementation have not yet been finalized, but in general we understand that:

Kaiser will continue to work with Board Certified Behavior Analysts (BCBA) and paraprofessionals (Line Therapists) under their supervision. Like most states, Oregon law does not currently require these providers to be licensed, and Kaiser has not imposed its’ own licensure requirements

Younger children with an autism diagnosis will receive a prompt initial approval for a limited amount of ABA therapy. After an assessment by the BCBA, Kaiser will approve additional services if medically necessary

For older patients, Kaiser’s own mental health department will conduct an assessment prior to approval of ABA

If you have Kaiser coverage, and would like ABA, you should now be able to get a referral from a Developmental Pediatrician – and expect it to be approved. If you have an appeal in process, we can probably exit the appeal process and get immediate coverage – please contact me for instructions. (If your appeal has been underway for a while, and you want coverage for the ABA services you’ve been receiving during the appeal, we may still want to complete it to ensure retroactive reimbursement). Regardless, if you have any problems with coverage, please contact me.

This change in Kaiser’s policy is a tremendous step forward on Kaiser’s part, and Kaiser deserves great credit for its’ leadership on this issue.

I personally thank the Autism Society of Oregon, Oregon Association for Behavior Analysis, the Portland Asperger’s Network, and Autism Speaks for their ongoing advocacy and government relations work to advance the cause of Autism Health Insurance Reform in Oregon. I also thank our legislators for passing the Mental Health Parity and Pervasive Developmental Disabilities legislation in 2005 and 2007 requiring insurers to cover autism as a mental health and medical condition which made this possible, and supporting our attempts at new more specific legislation; the Oregon Insurance Division for its’ help in processing and enforcing the numerous Independent Review decisions that helped motivate Kaiser’s policy change; the City of Portland (especially commissioners Amanda Fritz and Dan Saltzman) for leading the way with comprehensive autism coverage for city employees earlier this year; the media (especially the Lund Report and OPB’s Think Out Loud) for its’ coverage of this issue; and every single one of you who have ever contacted a legislator, submitted an insurance claim for autism treatment, filed a consumer complaint with the Insurance Division, or talked to a friend about this issue – your voices are being heard, and it’s making a difference.

Most of all, I’d like to thank everyone at Kaiser who has been working for implementation of this policy, and helping patients to navigate the appeals system over the past year while it has been in development.

Extended Coverage of Rehabilitative Therapy
Yesterday was a big day for our family in another way – we won an External Review decision requiring Kaiser to pay for up to 8 weeks of intensive multidisciplinary therapy (5 days per week, 8 hours per day) at the Kennedy Krieger Pediatric Feeding Disorders clinic at Johns Hopkins in Baltimore, Maryland to treat a severe autism-related feeding disorder for one of our boys. This decision – worth about $70,000 – effectively adds another 320 hours of speech and occupational therapy to the 20 hours of outpatient therapy normally covered under our plan.

Oregon law (ORS 743A.190) requires coverage of rehabilitative therapy (speech, occupational, and physical therapy) as a treatment for autism; Oregon insurers have been covering these services since that law was enacted in 2007, but generally impose strict visit limits – such as 20 hours per therapy per year – regardless of medical necessity. For group plans, these limits are probably in violation of the Federal mental health parity law, which requires any limits on mental health conditions – including autism – to be in parity with limits on physical and surgical conditions; since health benefit plans don’t normally limit visits for conditions like influenza, heart attacks, or broken bones to 20 visits per year, they can’t limit visits for autism to 20 per year.

We have, however, found a way around these visit limits: in addition to outpatient rehabilitative care, most health benefit plans also cover much more extensive multidisciplinary rehabilitative care. This is typically used to help patients recover from major accidents or illness, such as a stroke. Our own Kaiser plan covers 60 days of this therapy per year, in addition to the 20 hours of outpatient therapy per year. Oregon law (ORS 743A.190) states that if a benefit is available for any other medical condition, it must be available to treat autism – and we used this to require coverage of our son’s intensive treatment at Kennedy Krieger.

For Oregon’s rehabilitative therapy providers, I would encourage you to investigate ways of adding such multidisciplinary rehabilitative care options to your programs. This could range from an intensive 60-day therapeutic treatment program to a two week intensive “summer camp” to a weekly, 4-hour per session program combining speech and occupational therapy. I would be happy to talk to any providers about ways of structuring this.

ABA Coverage by Oregon’s Other Insurers
While Kaiser is now officially covering Applied Behavior Analysis (ABA) therapy, Oregon’s other insurers are lagging:

Providence: claims that its’ contract excludes all coverage for all Developmental Disabilities, including Autism; for commercial plans, this is unambiguously in direct violation of ORS 743A.168 and ORS 743A.190, which explicitly require coverage of Autism and Developmental Disabilities. Its’ attorneys have told us in writing that our only option is to file suit in court.

PacificSource: the U.S. District Court has already ordered PacificSource to provide coverage of ABA. Unfortunately, while the court specifically directed PacificSource to cover unlicensed BCBAs who were approved by the Oregon Department of Human Services, PacificSource refuses to do so and limits coverage to licensed providers (even though there is no license for ABA therapy). In the entire state of Oregon, PacificSource’s provider directory lists only one approved ABA provider who meets’ its credentialing requirements.

Regence: denies ABA coverage on grounds that the providers aren’t licensed. As noted above, Oregon law doesn’t require a license for ABA therapy.

United Healthcare: its’ contract explicitly excludes ABA therapy, even when medically necessary. This appears to violate ORS 743A.168 and ORS 743A.190, which require coverage of treatment for Autism, since ABA is widely accepted as a leading autism treatment. We have filed a complaint with the Oregon Insurance Division, which is investigating.

Oregon Health Plan (Medicaid): declares that ABA is experimental, and prohibits coverage. Last March, a judge in Florida ordered that state’s Medicaid program to cover ABA, and found that its’ position that ABA was experimental was “arbitrary, capricious, and unreasonable both in its process and in its conclusion.” It is noteworthy that Florida relied upon an expert from the OHSU Center of Evidence-based Policy in its’ unsuccessful defense – that’s the same organization behind OHP’s policy to exclude ABA coverage. Medicaid programs in several other states, including Washington and Michigan have settled or are in the process of settling class action lawsuits over improper exclusions of ABA coverage.

While we are working to develop new legislation for 2013 to explicitly mandate coverage of ABA therapy, and provide a licensing and credentialing process for ABA providers, the foundation for any new legislation must be compliance with and enforcement of the laws that we already have.

We have asked Oregon’s Insurance Division to enforce these laws, and will seek judicial solutions to enforce them ourselves by court order if necessary.

If you are interested in ABA therapy, we strongly urge you to ask your insurer to provide coverage. I will be working with the Autism Society of Oregon to provide instructions for preauthorization, reimbursement, and administrative appeals for each of Oregon’s insurers. In the event that we need to seek a court order, it will be important to demonstrate to the judge that many people have tried and failed to access the coverage that the law requires.

What You Can Do to Help
Without question, we’re winning our fight for Autism Health Insurance Reform. Our goal is to win quickly and comprehensively, so that everyone with autism can get the help that they need as soon as possible. There are about 50 new autism diagnoses in Oregon every month – I want every family to know the moment they receive that diagnosis that help is there for them.

There are several things you can do to help:

Contact your elected representatives: in the coming weeks and months, we’ll be working with the legislature and governor’s office to pass new legislation and enforce the laws that we have. As we do, we’ll keep you informed – and ask you to ask your elected officials to help us. Stay tuned, and be ready to give us a few minutes from time to time.

Volunteer: if you have more time, and are interested in volunteering, please write back to let me know. We will call a meeting for volunteers in the near future to talk about ways people can help.

Donate: the Autism Society of Oregon has hired a professional lobbyist, Shane Jackson, to help move this forward. Shane’s work has been fantastic, and has made a huge difference in navigating the system and meeting with the key stakeholders and decision makers. While our lobbying costs are remarkably low, ASO’s budget is very modest and they could really use our help to cover costs. Click here to make a tax-deductible donation; you can designate your donation “In Honor Of” Insurance Reform, and 100% will be used in support of this initiative.